Provider Demographics
NPI:1174557938
Name:GOLDBERG, MARSHALL (DDS, MSD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1435
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0349
Mailing Address - Country:US
Mailing Address - Phone:949-610-5513
Mailing Address - Fax:541-808-2768
Practice Address - Street 1:837 ZANNA PL
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2899
Practice Address - Country:US
Practice Address - Phone:949-610-5513
Practice Address - Fax:541-808-2768
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA186991223E0200X, 122300000X
CAG23273207NI0002X, 207NP0225X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No1223E0200XDental ProvidersDentistEndodontics
Yes122300000XDental ProvidersDentist
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA41900Medicare UPIN
CAAU565PMedicare PIN
CAAU565YMedicare PIN
CAAU565ZMedicare PIN
CAAU565XMedicare PIN
CAAU565NMedicare PIN
CAAU565WMedicare PIN